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SAN AULJIN LOCAL HEALTH DI."RICT <br /> UNpERGROUNp STORAGE TANr GROGRAM - FEE RORKSHEET ✓ <br /> F FACIlI1Y/SITE NAME FACILITY CONTACT NAME <br /> r RIuD RNL/prA pAINI MRR.�-E'1 DgvID F}I�DENP�RRtJD <br /> t <br /> L STREET ADDRESS SITE PHONE 1 AIITN ARSA eosin <br /> T— 221_ So. CH-ere-D{-GG7 LA.h7$_11� �-- SITE <br /> P--0- 31oe A CODE <br /> IT CITT _ �STAit1 IIP CODE�a 0l tanks <br /> QUpc i at site �OUIz C4) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P �R1uxHAUS�IJ t;NGWE ECtS <br /> BILL MAl'-1 w c+-► <br /> I MAILING ADDRESS — <br /> r APPLICANT PHONE 1 NIrN APIA coot <br /> p _`�(olz ROSEVILLt: izU(�D SUITE lo3 glrp �346 - 3os7 <br /> R CITY STAT 111"CODE TYPE of APPLICATION <br /> T—No9114---Ht!aHLAIJD5 C� 95�6o CLOSURE. INSTALLATION. RIC.ft��QTAI / TO <br /> I <br /> --- ------- _.--�- 1�•JJ'n LLAT `�/ <br /> FACILITY IEE = 1100.00 each SITE ADDRESS per YEAR. TOTAL <br /> 1986 1987 1988 1989 <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> ---- __ <br /> F 1 Tanks x 450.00 1986 1981 1988 1989 <br /> A (multioTy'I'by lee for IqQ l <br /> C each year applicable) <br /> —_ <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> I -- _ __ <br /> 1 1 Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter iiount and—year) --- -'-- =" -,7 <br /> _ 22oo <br /> 1 C PERMANENT CLOSURE (Removal or Closure-in-place) —_ <br /> CLOSURE FEE _ $30.00 each TANKI T ksISO <br /> --- ---- <br /> U ---- <br /> R TEMPORA"CLOSURE (Only alloyed one time for up to two years) \ <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK Tanks .00 <br /> - _--__ T ,—�1 Tanks � x (80.00 1 <br /> P PLAN CHECK (Installation or Repair) — <br /> 1 <br /> A - ----- ��d wtTy t ! Mova� <br /> MPLAN CHECK FEE 130.00 each SUBMISSION/RESUCMISSIptf <br /> REPAIR " ------ — <br /> R TANK REPAIR FEE = 1110.00 each TANK �- `� <br /> E 1 Tanks x 1110.00 $ <br /> A PIPING REPAIP,/CLOSURE/REnCYAI (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I -- --- --- --- _ <br /> R UNAUTHOR.IIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hrFEE = 135.00/hr� - — FEE = 135.001hr 1 <br /> ~ TOTAL DUE 1 zd , 00 <br /> Off ICE USE ON[r <br /> 'I i ! i i . R1^,�III�IiII�IIPI�alll�ll�l�llm�lil�'1!'i�1811f�f� fll .If�"ml�lli4"aTuTll11 I I���I�I�m'1I11�I�IlAm6 pM�I�fI�IV��?11f11�',!>mlQ <br /> SUEE�S r Cann I LOC COpE 01ST CODE AMOUIIT DUE AMOUNT RrvD CHECK 1/CASH RCVD DY DATE RECEIVED PERMIT 1 <br /> — <br /> I <br /> TII :� OJ��V I ! 'O-�PR �IIIPPII�pllllfl� "�IIII�III��!�P�!.1�1�1111111�1!I�II�"Pig 9PI�fl�llllllii�lllll�l�i�lll ��I�IIf' Ili, I�II�I��I�II�nII���I�I�I I�DMPIfi{h�I�111PI11�M�19�111,� <br />